Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug.

BACKGROUND: We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN: Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS: Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS: Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.

Determination of glomerular filtration rate using technetium-99m-DTPA with differing degrees of renal function.

UNLABELLED: Glomerular filtration rate (GFR) is an important index of renal function. Twenty-four-hour creatinine clearance overestimates GFR in patients with poor renal function. Inulin and iothalamate clearances are accepted reference standards for determining GFR but are expensive and laborious. We have previously reported that GFRs obtained by measuring the disappearance of 99mTc-DTPA from ultrafiltered (protein-free) samples of plasma were virtually identical to those obtained by the iothalamate method. However, the subjects used in that study had normal to only moderately decreased renal function. METHODS: The accuracy of measuring GFR by plasma clearance of 99mTc-DTPA was determined in subjects where renal function varied from normal to severely impaired. In all subjects, GFR was established by clearance of 125I-iothalamate from urine and serum and was used as the standard of reference. RESULTS: For subjects with normal to moderately diminished renal function (GFR > 20 ml/min), the correlation between values of GFR obtained by the DTPA and iothalamate methods was high (n = 18, r = 0.966). The difference between the pairs of GFR values obtained by the two methods was not statistically significant (p > 0.1). In patients with severe renal insufficiency (GFR < 20 ml/min), the correlation between the DTPA and iothalamate methods was poor (n = 11, r = 0.236), and the GFR values obtained by the two methods were statistically different (p < 0.01). CONCLUSION: These results suggest that GFR can be determined accurately by plasma clearance of 99mTc-DTPA in all patients except those with severe renal insufficiency.

Bilateral fatigue fractures of the radial shaft in a gymnast.

A 24-year-old female gymnast had a 3-month history of bilateral forearm pain. A Tc-99m MDP bone scan demonstrated focally increased activity in the radial shafts on blood pool and delayed images, characteristic of fatigue fractures. Fatigue fractures commonly occur in the lower extremities. Upper extremity fatigue fractures, in contrast, are uncommon and usually involve the humerus or ulna. Fatigue fracture of the radial shaft from gymnastic exercise has not been previously reported.

Scintigraphic appearance of bone during external beam irradiation.

Separate imaging studies employing Tc-99m MDP, In-111 labeled leukocytes, and Tc-99m SC were performed in a patient receiving external beam radiation therapy to the mediastinum and left hemithorax. The leukocyte scan demonstrated greatly increased activity at the site of the radiation port. The bone marrow (sulfur colloid) scan was normal and the bone scan demonstrated only minimally increased activity in the irradiated region. The varying appearance of these scans may represent the difference in the early effect of radiation on bone and bone marrow elements.

The efficacy of indium-111-polyclonal IgG for the detection of infection and inflammation.

UNLABELLED: The purpose of this study was to determine the efficacy of 111In-polyclonal immunoglobulin (IgG) for the diagnosis of infection or inflammation. METHODS: Fifty-three patients with suspected infection were prospectively studied. Each underwent an 111In-polyclonal IgG study; biopsy, surgery, additional nuclear medicine scans and radiographic studies were used to confirm the IgG scan results. RESULTS: The polyclonal IgG scan had a sensitivity of 97.9% and a specificity of 94% for infection or inflammation. When only infection or severe inflammation such as bowel infarction was considered, the sensitivity remained the same but the specificity fell to 83%. Chronic infections were detected equally as well as acute infections. Antibiotics, steroids, anti-inflammatory agents, diabetes and diminished renal function did not affect scan sensitivity. There were no adverse reactions to the radiopharmaceutical. Three patients underwent extended imaging. Their scans stayed positive for an average of 8 days. Three patients treated for infection had their scans turn negative on repeat study, confirming the efficacy of their antibiotic therapy. CONCLUSION: Indium-111-polyclonal IgG is an effective imaging agent of infection and/or inflammation that is useful in a variety of infections and in severe inflammatory diseases. The ease of preparation and safety make it an attractive alternative to labeled leukocytes.

Distribution of gallium-67 in normal and hypotransferrinemic tumor-bearing mice.

The mechanism by which 67Ga accumulates in tumors is controversial. The most popular theory is that 67Ga binds to transferrin and gains access to cells by the transferrin receptor. However, substantial evidence suggests that uptake of 67Ga may not be universally mediated by transferrin in tumors. To determine whether transferrin is required for uptake of 67Ga in vivo, we compared the uptake of 67Ga by two types of implanted tumors and by normal tissues in normal and severely hypotransferrinemic strains of Balb/C mice. One type of tumor was strongly gallium-avid in normal mice; the other was not. Uptake of 67Ga by normal soft tissues was markedly less in hypotransferrinemic than in normal mice. Uptake of 67Ga by bone was equivalent in the two types of mice. For the more gallium-avid tumor, uptake of 67Ga was similar and the ratio of tumor-to-background activity was substantially higher in the hypotransferrinemic than in the normal mice. For the less gallium-avid tumor, uptake was significantly less in hypotransferrinemic than in normal mice. These data suggest that uptake of 67Ga by bone and by some tumors may be a transferrin-independent process.

Cerebrovascular accident associated with dipyridamole thallium-201 myocardial imaging: case report.

A patient with known aortoiliac occlusive disease and hypertension suffered a cerebrovascular accident 6.5 min after the administration of intravenous dipyridamole during a 201Tl myocardial study. Despite aminophylline administration, the patient developed a completed stroke. The mechanism most likely responsible for precipitating this patient's stroke is dipyridamole-induced vascular steal. Although dipyridamole-201Tl myocardial imaging is relatively free of major complications, the morbidity and mortality associated with a cerebrovascular accident is significant. The possibility of precipitating a cerebrovascular accident during dipyridamole-201Tl imaging should be considered in all patients with significant risk factors for stroke before performing a dipyridamole cardiac study.

Embolization of hepatic arteriovenous malformations using radiolabeled and nonradiolabeled polyvinyl alcohol sponge in a patient with hereditary hemorrhagic telangiectasia: case report.

Polyvinyl alcohol sponge (PVA) radiolabeled with 99mTc-sulfur colloid was used to evaluate a large hepatic arteriovenous malformation (AVM) in a 71-yr-old white female prior to embolization. The patient had hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) with severe left-to-right shunting through the hepatic AVM which resulted in high-output congestive heart failure. The patient also had severe pulmonary hypertension. Scintigraphic imaging of the embolized radiolabeled PVA particles allowed us to be certain that the particles did not flow through the liver and inadvertently embolize the lungs; with the patient's already poor pulmonary status, embolization could have been fatal.

Temporal progression of cortical reorganization following nerve injury.

Damage to peripheral nerves of adult mammals causes reorganization of somatosensory maps in the cerebral cortex. An understanding of the temporal progression of cortical changes is important for understanding the underlying mechanisms. The present experiments utilized neurophysiological recordings to analyze the time course of reorganization in the S-I cortical hindpaw area in adult rats. Following loss of sciatic inputs, the cortical area responding to low threshold inputs from the hindpaw saphenous nerve expands. A brief, early onset period of rapid expansion is followed by a prolonged period of slow increase. The temporal progression suggests that early onset changes condition the central nervous system for later changes.

In situ hybridization analysis of chromosomal homologies in Drosophila melanogaster and Drosophila virilis.

Twenty-four biotin-labeled recombinant-DNA probes which contained putative unique-sequence Drosophila melanogaster DNA were hybridized to larval salivary-gland chromosomes of D. melanogaster and Drosophila virilis. All probes hybridized to D. melanogaster chromosomes at the expected sites. However, one probe hybridized to at least 16 additional sites, and one hybridized to one additional site. Thirteen probes hybridized strongly to D. virilis chromosomes, four hybridized weakly and infrequently, and seven did not hybridize. Probes representing two multigene families (beta-tubulin and yolk-protein) hybridized as would be expected if all sites had been conserved in the two species on the same chromosomal elements. The multiple hybridization sites of a third probe which may represent a multigene family were also conserved. The results were consistent with H.J. Muller's proposal that chromosomal elements have been conserved during evolution of this genus.